Rapid communication: minimally invasive urologic surgery curricula

PURPOSE: Surgical education programs are being challenged to provide comprehensive training in the ever-expanding technologies and techniques. We present dedicated training curricula for several aspects of minimally invasive urologic surgery in an effort to provide a uniform training experience for all residents. MATERIALS AND METHODS: Five components of the curricula were developed, namely, cognitive objectives, skills objectives, competency of procedures, cognitive evaluation, and proficiency or skills evaluation. RESULTS: The five components of the curriculum were defined specifically for cystoscopy and transurethral surgery, ureterorenoscopy and intrarenal surgery, renal access surgery, and laparoscopic urology. CONCLUSION: This standardized curriculum overview for minimally invasive urologic surgery is an initial attempt to define one aspect of a urology training program. We hope these curricula will serve as a basis for further discussion and development of a comprehensive urology training program.     

Residency Training Program Paradigms for Teaching Robotic Surgical Skills to Urology Residents

The advent of laparoscopic and robotic techniques for management of urologic malignancies marked the beginning of an ever-expanding array of minimally invasive options available to cancer patients. With the popularity of these treatment modalities, there is a growing need for trained surgical oncologists who not only have a deep understanding of the disease process and adept surgical skills, but also show technical mastery in operating the equipment used to perform these techniques. Establishing a robotic prostatectomy program is a tremendous undertaking for any institution, as it involves a huge cost, especially in the purchasing and maintenance of the robot. Residency programs often face many challenges when trying to establish a balance between costs associated with robotic surgery and training of the urology residents, while maintaining an acceptable operative time. Herein we describe residency training program paradigms for teaching robotic surgical skills to urology residents. Our proposed paradigm outlines the approach to compensate for the cost involved in robotic training establishment without compromising the quality of education provided. With the potential advantages for both patients and surgeons, we contemplate that robotic-assisted surgery may become an integral component of residency training programs in the future.     

Accreditation council on graduate medical education technical skills competency compliance: urologic surgical skills

BACKGROUND: In accordance with new mandates implemented by the Accreditation Council on Graduate Medical Education, reliance on operative case logs as demonstration of residents' surgical competence will no longer be adequate. We describe the implementation of a comprehensive, year-round, mandatory skills laboratory curriculum as an integral component of our urology residency training program. STUDY DESIGN: We developed eight laboratory practicums using primarily nonhuman models: basic endoscopy, advanced endoscopy, ureteroscopy, percutaneous renal surgery, basic laparoscopy, advanced laparoscopy, urologic use of the gastrointestinal tract, and cadaveric pelvic dissection. RESULTS: Anonymous evaluations submitted by all training session participants indicate that acquisition of surgical skills is facilitated through participation in laboratory practicums. An incremental progression in proficiency was observed by all of the instructors and students who participated. There was a high degree of satisfaction with model fidelity and the value of technical experience gained. CONCLUSIONS: Our urologic surgery skills laboratory curriculum is an effective means of skills acquisition and maintenance for a wide variety of urologic techniques, including complex endourologic procedures. Patient care can safely be of secondary importance with respect to trainee experience in a low-stress environment that provides an opportunity for supervised repetitive performance of essential technical skills. We describe effective models, with high fidelity-to-cost ratio, that incorporate laboratory-based surgical skills training and evaluation into urology residency programs, with the aim of Accreditation Council on Graduate Medical Education competency guideline compliance.     

Canadian consensus conference on the development of training and practice standards in advanced minimally invasive surgery: Edmonton,Alta., Jun. 1, 2007

Despite the complexities of minimally invasive surgery (MIS), a Canadian approach to training surgeons in this field does not exist. Whereas a limited number of surgeons are fellowship-trained in the specialty, guidelines are still clearly needed to implement advanced MIS. Leaders in the field of gastrointestinal surgery and MIS attended a consensus conference where they proposed a comprehensive mentoring program that may evolve into a framework for a national mentoring and training system. Leadership and commitment from national experts to define the most appropriate template for introducing new surgical techniques into practice is required. This national framework should also provide flexibility for truly novel procedures such as natural orifice translumenal endoscopic surgery.     

Learning curve for the two-incision total hip replacement

Recently there has been increased interest in doing total hip replacement through small incisions. One such technique is the two-incision approach. After initial investigations into its feasibility, Zimmer developed a training program for surgeons interested in doing the so called MIS 2-Incision Hip Procedure. An "index case" study was initiated to track the early experiences of trained surgeons, which includes 159 surgeons who have completed such training and recorded data on their initial cases. The purpose of this report is to present the data available from this index case study regarding the process of developing proficiency with the two-incision total hip replacement. We found a significant decrease in the mean operative time and fluoroscopy time from the first to tenth case. Key complications did not show a systematic decrease as a function of case number for the first ten cases. Clarification of the entire learning curve for this technique requires further investigation but may last beyond case ten for many surgeons. In addition, data from this study suggests that patient characteristics and surgeon experience have a significant effect on the prevalence of complications with the two-incision technique. The evolution of minimally invasive joint replacement is clearly in its infancy. Complication rates and the demonstrated learning curve may be altered by changes in training and surgical techniques.     

Ongoing deficits in resident training for minimally invasive surgery

Patient preference has driven the adoption of minimally invasive surgery (MIS) techniques and altered surgical practice. MIS training in surgical residency programs must teach new skill sets with steep learning curves to enable residents to master key procedures. Because no nationally recognized MIS curriculum exists, this study asked experts in MIS which laparoscopic procedures should be taught and how many cases are required for competency. Expert recommendations were compared to the number of cases actually performed by residents (Residency Review Committee [RRC] data). A detailed survey was sent nationwide to all surgical residency programs (academic and private) known to offer training in MIS and/or have a leader in the field. The response rate was approximately 52%. RRC data were obtained from the resident statistics summary report for 1998–1999. Experts identified core procedures for MIS training and consistently voiced the opinion that to become competent, residents need to perform these procedures many more times than the RRC data indicate they currently do. At present, American surgical residency programs do not meet the suggested MIS case range or volume required for competency. Residency programs need to be restructured to incorporate sufficient exposure to core MIS procedures. More expert faculty must be recruited to train residents to meet the increasing demand for laparoscopy. Presented at the Forty-Second Annual Meeting of The Society for Surgery of the Alimentary Tract, Atlanta, Georgia, May 20–23, 2001 (oral presentation). Supported in part by an educational grant from Tyco/U.S. Surgical Corporation.     

Training program for minimally invasive surgery]

Currently 'Minimally Invasive Surgery' (MIS) is rapidly finding a widening range of applications and increasing numbers of surgical departments start with new MIS techniques. Surgical work under endoscopic control requires an intensive readjustment to operation technique bringing about new problems in training. We believe that intensive training of MIS procedures on suitable training phantoms should be a prerequisite for clinical application of MIS and therefore have established a training center for MIS in Tübingen, FRG, offering weekly hands on training courses for different procedures.     

Toward effective pediatric minimally invasive surgical simulation

Background/Purpose

Simulation is increasingly being recognized as an important tool in the training and evaluation of surgeons. Currently, there is no simulator that is specific to pediatric minimally invasive surgery (MIS). A fundamental technical difference between adult and pediatric MIS is the degree of motion scaling. Smaller instruments and areas of dissection under greater optical magnification require finer, more precise hand movements. We hypothesized that this can be used to detect differences in skills proficiency between pediatric and general surgeons.

Methods

We programmed a virtual reality simulation of intracorporeal suturing with modes that used motion scaling to mimic conditions of either adult or pediatric MIS. The participants consisted of pediatric and general surgeons who wore motion-sensing gloves. Metrics included time elapsed, penetration errors, tool movement smoothness, hand movement smoothness, and gesture level proficiency.

Results

For all measures, pediatric surgeons demonstrated superior proficiency on exercises conducted in pediatric conditions (P < .05). Performance in adult conditions was similar between the 2 groups.

Conclusion

Pediatric surgeons possess unique skills compared with general surgeons that relate to the technical challenges they routinely face, reinforcing the need for a surgical simulator specific to pediatric MIS. This validates our simulator and the manipulation of motion scaling as a useful training tool.     

Initial experience with laparoscopic hepatic resection at a comprehensive cancer center

Background  

Over the past few years, surgeons have been able to obtain training in advanced minimally invasive surgery (MIS) for hepatic, pancreatic, and biliary (HPB) cases instead of having to teach themselves these complex techniques. As a result, the initial experience of a surgeon with advanced MIS HPB training at a national cancer center was reviewed.     

Telesurgery. Remote monitoring and assistance during laparoscopy

In comparison to open surgery, laparoscopy results in less postoperative pain, shorter hospitalization, more rapid return to the work force, a better cosmetic result, and a lower incidence of postoperative intra-abdominal adhesions. These advantages are indisputable when comparing large series for cholecystectomy and smaller series for pelvic lymph node dissection, nephrectomy, and bladder neck suspension in experienced hands. Urologists have an obligation to explore the application of these methods to urologic disease and to adjust the standard of care accordingly. Several barriers to the expansion of urologic laparoscopic surgery exist. The experience in extirpative and reconstructive urologic procedures is limited when compared with the data on cholecystectomy. These procedures are technically complex and demand advanced laparoscopic skills and familiarity with laparoscopic anatomy. The steep learning curve translates into long operative times and an unacceptably high rate of complications for inexperienced laparoscopic surgeons. Most practicing urologists have no formal training in advanced laparoscopy, and no formal credentialing guidelines exist. Telesurgical technology may provide one solution to this problem. Through telesurgical mentoring, less experienced surgeons with basic laparoscopic skills could receive training in advanced techniques from a world expert without the need for travel. These systems could also be used to proctor laparoscopic cases for credentialing purposes and to provide a more uniform standard of care. This review has outlined some of the exciting progress made in the field of telesurgery over the past 10 years and described some of the technical and legal obstacles that remain to be surmounted. During the 1990s, urologists were at the forefront of innovation in remote telepresence surgery. As the scope of minimally invasive urologic surgery expands during the first few decades of the twenty-first century, telesurgical mentoring should have an increasingly important role.     

Complication management in minimally invasive spinal surgery

Minimally invasive spine surgery (MIS) allows for the treatment of spinal abnormalities with considerably decreased soft tissue disruption and post-operative pain which has been associated with shorter hospitalizations and earlier mobilization. However, MIS procedures have a steep learning curve, offer decreased visualization, and require more advanced technical proficiency which may lead to the occurrence of a technical complication. This review examines common complications associated with various MIS procedures and provides suggestions for risk mitigation and complication management.     

Patient selection for minimally invasive spine surgery

Minimally invasive approaches to treat lumbar spine disease may carry many benefits over traditional open surgery with comparable patient outcomes. However, this advantage is conferred through appropriate patient selection. Not only do patient-specific anatomic factors influence the use of these techniques, but also surgeon familiarity with approaches. Adult spinal deformity surgery represents an area where minimally invasive spine (MIS) techniques have demonstrated significant impact in appropriately selected patients. Conversely, applying MIS techniques in patients inappropriate for minimally invasive surgery can result in complications, reoperations, and adverse outcomes. This chapter will highlight algorithms to guide patient and technique selection for MIS deformity surgery.     

Minimally invasive surgery training in Canada

BACKGROUND: The purpose of this study was to assess the state of surgical training in minimally invasive surgery (MIS) within Canadian academic surgical departments. METHODS: A pretested questionnaire was distributed to the general surgery residents of participating Canadian academic surgical departments. RESULTS: Fourteen of 16 residency programs participated and 235 of 388 residents (60%) responded to the survey. Residents expect to perform both basic (217/235 [92%]) and advanced (123/234 [53%]) MIS procedures on completion of their residency. However, only 41 of 233 (18%) believed that their advanced MIS training would be adequate. On a Likert scale, the most important factors influencing their training included limited advanced case volume (median, 5), limited opportunity in the operating room (OR) (median, 5), lack of attending surgeon interest (median, 4), limited OR time (median, 4), and a lack of surgical department support (median, 4). Residents were concerned about their ability to acquire these skills once they finished their training (median, 4), and 231 of 234 (99%) thought that there was an important role for a MIS surgeon within the academic setting (median, 5). CONCLUSION: The rapid development of MIS has generated complex issues for resident training within the present Canadian academic surgical environment.     

The role of the psychiatrist in myelodysplasia.

Management of the myelodysplasia patient and his family is best performed in the multidisciplinary setting of a comprehensive care clinic. Careful initial evaluation by each subspecialist on the team followed by family counseling provides the basis for selection of patients for treatment. Subsequently each subspecialist contributes up-to-date assessment and on-going medical care. Prevention of progressive orthopedic deformity through the use of plaster casts may minimize the need for surgical treatment. Severe deformities may require muscle balancing procedures. Aggressive surgical intervention is indicated in cases of progressive scoliosis and lordoscoliosis. Minimal urologic evaluation and surveillance guidelines have been developed, and prevention of irreversible renal damage is possible. Chemotherapy, adequate bladder drainage, and sophisticated techniques including sphincter and bladder electromyography and the use of artificial urinary sphincters and bladder pacemakers contribute to improved urologic management. The emotional needs of the patient and his family are complex, and support by the psychiatrist and the social worker as well as all other team members is necessary for adequate development of a well adjusted child in the face of physical handicaps.     

Minimally invasive techniques in treatment of adult spinal deformity

MIS for the correction of ASD represents a continuously evolving surgical field. As the incidence of ASD continues to increase in the aging population, MIS offers an effective alternative means of surgical intervention while reducing the significant perioperative morbidity associated with traditional open techniques. MIS is not without risk; however, optimized patient selection can minimize complication risk and produce favorable clinical and radiographic outcomes. This review seeks to highlight appropriate patient selection, indications, complications, and areas in need of further investigation to evaluate long-term outcomes of these novel surgical techniques.     

Videotape mentoring and surgical simulation in laparoscopic courses

As laparoscopic approaches to core urologic procedures continue to supplant their open counterparts, the demand to train urologists who received inadequate exposure to these techniques during residency has intensified. The acquisition of laparoscopic skills has been aided greatly by the introduction of hand-assisted laparoscopic surgery (HALS). In another training method, participants completed the standard animate and inanimate course training, then entered a mentoring relationship with their instructor, including an observational period and performance of several complex laparoscopic operations with the assistance of the mentor surgeon. However, the time commitment, compensation issues, and need for temporary operating privileges are obstacles to this approach. A number of studies have demonstrated that laparoscopic skills can be measured on a videotrainer and that ability improves with repetitive performance. Senior urologists with minimal initial knowledge may benefit from laparoscopic skills training videotape analysis and critique. Laparoscopic simulators can improve, not only the psychomotor skills required to perform laparoscopy, but operative performance as well. Ultimately, preoperative images and data may be interfaced with robotic simulation software to allow practice of virtual operations with realistic tissue photo-representation prior to performing them on patients. Improvements in laparoscopic surgical simulation and application of these newly acquired skills to a simulated patient will ultimately eliminate the learning curve on actual patients and provide a useful means of establishing competence.     

Pediatric reconstructive surgery

The field of reconstructive pediatric urologic surgery is constantly changing. Recent changes in pediatric urologic reconstructive surgery are discussed in the present review. Surgical techniques for treating patients with hypospadias, exstrophy, incontinence, and ambiguous or variant genitalia are also discussed.     

Virtual reality simulation for the operating room: proficiency-based training as a paradigm shift in surgical skills training

SUMMARY BACKGROUND DATA: To inform surgeons about the practical issues to be considered for successful integration of virtual reality simulation into a surgical training program. The learning and practice of minimally invasive surgery (MIS) makes unique demands on surgical training programs. A decade ago Satava proposed virtual reality (VR) surgical simulation as a solution for this problem. Only recently have robust scientific studies supported that vision METHODS: A review of the surgical education, human-factor, and psychology literature to identify important factors which will impinge on the successful integration of VR training into a surgical training program. RESULTS: VR is more likely to be successful if it is systematically integrated into a well-thought-out education and training program which objectively assesses technical skills improvement proximate to the learning experience. Validated performance metrics should be relevant to the surgical task being trained but in general will require trainees to reach an objectively determined proficiency criterion, based on tightly defined metrics and perform at this level consistently. VR training is more likely to be successful if the training schedule takes place on an interval basis rather than massed into a short period of extensive practice. High-fidelity VR simulations will confer the greatest skills transfer to the in vivo surgical situation, but less expensive VR trainers will also lead to considerably improved skills generalizations. CONCLUSIONS: VR for improved performance of MIS is now a reality. However, VR is only a training tool that must be thoughtfully introduced into a surgical training curriculum for it to successfully improve surgical technical skills.     

Laparoscopy influences hiring practices within academic surgical departments

Background  This study aimed to determine whether the increasing emphasis on minimally invasive surgery (MIS) influences hiring practices within academic surgical departments. Methods  A questionnaire was mailed to chairs of surgery departments and divisions of general surgery at the 16 Canadian academic institutions. Nonresponders were identified and contacted directly. The survey consisted of 34 questions, including Likert scales, single answers, and multiple-choice questions. Data were collected on demographics, perceptions of MIS, and recruitment/hiring. At the time of the survey, two department chair positions were vacant. Results  A response rate of 87% (26/30) was obtained, with representation from 94% of departments (15/16). Of those surveyed, 88% intend to increase the importance of MIS at their institution within 5 years, and 87% intend to achieve this objective through new hirings. Networking (73%) and retention of recent graduates (89%) were cited most frequently as recruitment strategies. Strengthening the division, research, and education were considered important or extremely important by more than 90% of the respondents with respect to recruitment goals, whereas strengthening MIS was considered important or extremely important by 50%. Within 5 years, surgical departments intend to hire a median of four general surgeons, 50% of whom will have formal MIS training. In comparison, over the past 10 years, only 25% of new recruits had formal MIS training. More than 90% of the respondents considered formal MIS fellowship, MIS fellowship plus a second fellowship, and proctorship to be adequate training for performing advanced MIS, whereas traditional methods were considered inadequate. Lack of operative time and resource issues were considered most limiting in the hiring of new MIS surgeons. Conclusion  Minimally invasive surgery is growing in importance within academic surgical departments, but it remains an intermediate recruitment priority. Formal MIS training appears to be important in the recruiting of new surgeons, whereas traditional training methods are considered inadequate. Poster presentation at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) annual meeting, Las Vegas, NV, 18–22 April 2007.     

Simulation in surgery. Where are we now and where to from here?

With the introduction of new techniques and technologies, operative skills became a crucial part of surgical competence, deserving more attention. Implementation of validated simulation modalities into the training curriculum is emphasized. It became obvious that operative skills should be brought to an adequate level of proficiency using different available approaches. At the dawn of the 21st century it became apparent that the use of simulation to train and to assess technical surgical skills provided a good solution to offset the curtailed apprenticeship system. The current state and future perspectives of simulation in surgical training are discussed. Development and use of multimodality simulation supported by e-learning, video-learning in web-based modules, is needed to support the apprenticeship system in order to achieve the necessary competences to become an expert surgeon.